Never Events
Never Events are defined as ‘serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations’. They are considered to be different from other patient safety incidents as a single Never Event is a ‘red flag’ that the healthcare provider does not have robust systems for implementing existing safety advice/alerts.
The NHS has produced a list of Never Events which includes the following:
- Wrong site surgery
- Wrong implant/prosthesis
- Retained foreign object post procedure
- Mis-selection of a strong potassium solution
- Administration of medication by the wrong route
- Overdose of insulin due to abbreviations or incorrect device
- Overdose of methotrexate for non-cancer treatment
- Mis-selection of high strength midazolam during conscious sedation
- Failure to install functional collapsible shower or curtain rails
- Falls from poorly restricted windows
- Chest or neck entrapment in bed rails
- Transfusion or transplantation of ABO-incompatible blood components or organs
- Misplaced naso- or oro-gastric tubes
- Scalding of patients
- Unintentional connection of a patient requiring oxygen to an air flowmeter
The NHS monitors and reports on the number and frequency of Never Events. Between April 2024 and August 2024 there were 154 Never Events recorded across the NHS. Of these, the most common issues were wrong site surgery (70 incidents) and retained foreign object post procedure (45 incidents). The worst performing Trust was University Hospitals of Derby and Burton NHS Foundation Trust which recorded five Never Events in the period.
Whilst the majority of Never Events are identified and rectified relatively quickly, patients still endure a prolonged period of pain, suffering and loss of amenity if, for example, they have had to undergo an x-ray to locate a retained swab and then a second anaesthetic and reopening of a surgical site to remove it. The specialist medical negligence team at O’Donnell Solicitors has experience of working with client to identify the extent of the avoidable injury and loss caused by a Never Event and fighting for appropriate compensation.
